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Late Outcomes Following Open and Endovascular Repair of Blunt Thoracic Aortic Injury
Study Questions:
What are the long-term outcomes following open and endovascular repair of blunt thoracic aortic injury (BTAI)?
Methods:
In this single-institution study, 109 patients from 1992-2010 underwent repair for BTAI. Open descending thoracic aortic repair (DTAR) was performed in 90 (85 with left heart bypass, 5 with hypothermic arrest), and thoracic endovascular aneurysm repair (TEVAR) was used in 19 patients. A strategy of delayed repair was used preferentially after 1997. The authors employed permissive hypertension, avoided the clap and sew technique, preserved intercostals whenever possible, and used left carotid-subclavian bypass regularly for TEVAR patients. Primary outcome for the study was long-term survival at the time of the study (100% follow-up, mean 103.9 months). Secondary outcomes were early mortality and morbidity, specifically stroke, spinal cord injury (SCI), and dialysis.
Results:
The mean age of the cohort was 39 ± 18.2 years and 73.4% were male. Technical success was achieved in all patients where TEVAR was attempted. (Gore TAG n = 13, Medtronic Talent n = 3, AneuRx n = 1, and Cook TX2 n = 2). Five early deaths occurred, all in DTAR patients, from multiorgan failure (n = 2), intra-abdominal hemorrhage (n = 1), or diffuse axonal injury (n = 2). Three strokes occurred (TEVAR n = 2, DTAR n = 1). Two patients had SCI, all in the DTAR group, and renal failure occurred in 11 patients, with only 3 patients requiring hemodialysis permanently. Using a composite outcome of death, stroke, SCI, and dialysis, age >60 (odds ratio [OR], 8.4), increasing preoperative creatinine (OR, 7.9), and postoperative sepsis (OR, 9.6) independently predicted the composite event. Crude mortality for the study was 14.7% (16 patients). Mean survival time for the entire cohort was 189.8 months. Late mortality was predicted by age >60 (hazard ratio [HR], 4.1), increasing creatinine (HR, 9.1), or postoperative sepsis (HR, 20.6). Freedom from reintervention at 15 years was 99%, with only one patient from the TEVAR group requiring placement of a Z-stent for treatment of a type Ia endoleak during the study.
Conclusions:
Despite an increased risk of reintervention, open or endovascular repair of BTAI has excellent early and late results in selected patients. TEVAR appears to have a role in treatment of BTAI in anatomically appropriate patients.
Perspective:
Many centers have adopted an endovascular first approach to treatment of BTAI. In this study, TEVAR for BTAI was associated with excellent results. Other studies have shown that an endovascular approach can be associated with significant device-related complications including significant rates of endoleaks. I believe that the excellent outcomes reported in this single-institution study are the result of careful selection of patients for TEVAR and a willingness to perform open repair when possible.
Keywords: Renal Dialysis, Endovascular Procedures, Follow-Up Studies, Aortic Aneurysm, Thoracic, Diffuse Axonal Injury, Heart Bypass, Left, Hypertension
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